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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800987
Report Date: 06/16/2026
Date Signed: 06/16/2026 02:24:20 PM

Document Has Been Signed on 06/16/2026 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:IRENE'S BOARD & CAREFACILITY NUMBER:
405800987
ADMINISTRATOR/
DIRECTOR:		ANGELITA O. MARAVILLASFACILITY TYPE:
740
ADDRESS:220 VIA PROMESATELEPHONE:
(805) 227-0276
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 3DATE:
06/16/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Licensee/Administrator - Angelita MaravillasTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 6/16/2026 at 9:10am, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 7/1/2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Licensee/Administrator Angelita Maravillas and explained the reason for the visit.

LPA and Licensee toured the facility for health and safety concerns. LPA tested the hot water at 109.8°F, within regulation temperatures 105-120°F. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility had no obstructions in hallways, doorways or exits.

LPA and Licensee conducted a medication audit and reviewed the facilities Centrally Stored Medication and Destruction Records(CSMDRs). At 10:16am LPA observed a physician order dated 3/30/2026 for Resident #1 (R1) that stated memantine hcl 10MG take one tablet by mouth daily. The facilities medication administration record(MAR), CSMDR, and the medication bottle for R1 all state memantine hcl 5mg take one tablet by mouth daily. The Licensee states they over looked the dosage of 10mg on the physician order and that they have been giving R1 one 5mg tablet once daily. The Licensee called the physician for clarification and received an updated order during the visit. At 10:55am the LPA noted a physician order for Resident #2 (R2) stating seroquel 25mg take 1-2 tablets by mouth at bedtime as needed for agitation/sleep disturbances. R2's MAR for June 2026 indicates R2 has received seroquel 25mg twice daily at 8:00am and 4:00pm. The Licensee states R2 typically goes to bed between 6:00pm - 7:00pm.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
VISIT DATE: 06/16/2026
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The Licensee also stated that R2's physician is aware they are receiving the medication twice daily routinely and not at bedtime. The Licensee states they do not have a physician order stating this but that they have requested one and so has R1's family, from the physician. R2's record reveals there is no physician order stating if R2 can determine their need for a PRN medication or if they can communicate their symptoms.

During LPA visit conducted on 3/11/2026 Licensee was cited for not following physician orders, they submitted their plan of correction by the due date. Today's visit revealed the Licensee continues to not follow physician orders.

LPA and Licensee reviewed staff training noting required documentation and hours.

Exit interview conducted, deficiencies cited on LIC809-D page, an immediate civil penalty in the amount of $250 for a repeat violation within twelve months is being assessed on the attached LIC421FC, reports signed, and reports provided to Licensee.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2026 02:24 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 06/16/2026 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2026
Section Cited
CCR
87465(a)(4)

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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee obtained an updated physician order for the memantine during the LPA visit and is working to obtain the updated seroquel order by tomorrow. Licensee will email LPA the updated seroquel order when received and a statement of understanding of this regulation by 6/17/2026.
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Based on observation, interview and record review, the licensee is not providing residents their medications as prescribed, which poses an immediate Health, Safety, Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
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